Performance Improvement Plan

Review below the performance measurements for the Emergency Management Program 2014 and 2015.

Performance Measurements for Emergency Management Program 2014

*Performance* *Indicators*	Goal/Ql	*1^st Qtr.*	*2^nd Qtr.*	*3^rd Qtr.*	*4^th Qtr.*	*YTD*	*Analysis*
Incorporate four decontamination drills per year into the Emergtency Management Program	4/yr (1/Qtr)	Yes	Yes	Yes	Yes	100%	From October till November 2014 over 1000 staff members were trained in wearing Level C Suits and Purified Air Powered Respirators during the drills for Ebola. The Security team drills and trains annually with the DRC in HAZMAT The Emergency Department performed annual HAZMAT and Mark 1 kit competencies as part of their annual education in May 2014
	*Goal/Ql*	*1^st Qtr.*	*2^nd Qtr.*	*3^rd Qtr.*	*4^th Qtr.*	*YTD*	*Analysis*
Physicians will be trained in CBRNE and hospital decontamination via the House Staff Noon Conferences	100%	Yes	Yes	Yes	Yes	100%	Physician noon conference held every month on Chemical, Biological/Pandemic, Explosive and Radiation events, blast trauma, START triage as well as Doctor Decon classes throughout the year.
Leadership Team Directors and Managers will complete the NIMS ICS trainings on line FEMA courses for HICS ICS 100HC, 200HC, 700,800	100%	No	No	No	No	50%	Only 50% of hospital directors have completed NIMS ICS courses- bring to leadership meeting and put on line on Health Stream

*Performance* *Indicators*	Goal/Ql	*1^st Qtr.*	*2^nd Qtr.*	*3^rd Qtr.*	*4^th Qtr.*	*YTD*	*Analysis-plan for 2015*
Incorporate Active Shooter Drills into every fire/evacuation training done in hospital in 2015	4/yr (1/Qtr) 100%						Start with OR training and education. Coordinate a Fire/OR/Active shooter and evacuation drill in February 2015 Train all NICU staff on high risk infant evacuation with WEE VAC sleds and pouches. Train NICU nurses on Active Shooter as well as evacuation with head lamps for vertical and horizontal evacuation.
	*Goal/Ql*	*1^st Qtr.*	*2^nd Qtr.*	*3^rd Qtr.*	*4^th Qtr.*	*YTD*	*Analysis*
	100%						Plans to replace the SAT RAD phones in the hospital as well as upgrade Everbridge to X matters. Plans to host HAM radio bimonthly meetings at SMMC
Leadership Team Directors and Managers will complete the NIMS ICS trainings on line FEMA courses for HICS ICS 100HC, 200HC, 700,800	100%						Email all leaders list each month of compliance with NIMS training. Also bring to leadership meeting and put all course on line on Health Stream. Re email the link to FEMA classes to all managers and directors and Senior Leadership.